Steven Waldman

How to Defuse the Abortion Issue on Health Care Reform

Lost in the vitriol about abortion is a surprising development: key pro-life and pro-choice leaders both say they don’t intend to use health care reform to shift the balance of power in their direction. Activists have said health care reform should reflect the status quo in the abortion stalemate.
Less surprisingly, while both sides agree on that goal, they look at the same words in the same bills and come to opposite conclusions about what they mean. For instance, the bill passed by the House Energy and Commerce Committee declares, “Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage” for abortion in the “public option.” Pro-choicers say that this neither-this-nor-that language is self-evidently neutral. Pro-life activists argue that since abortion “could” be covered, it will be covered, a not unreasonable assumption given that, as written, it would be up to the Obama administration to make the determination.
My personal view: the legislation passed by the House Energy and Commerce Committee does not mandate abortion coverage, as pro-life groups claim, but does leave open the possibility that the government might pay for abortion. And the “neutral” amendment offered by pro-lifers didn’t achieve neutrality either, as it would potentially roll back abortion coverage in private insurance plans.
Of course it’s easy me to criticize everyone for not coming up with a neutral solution. It’s always more fun to carp than be constructive. So here’s my best effort on how to make health care reform neutral on abortion.
First, we need to recognize that part of the problem in being neutral is that health care reform would introduce some new features so you really can’t just freeze the status quo. Instead, one has to look at general principles. In general, the federal government is currently prohibited from directly paying for abortion but allowed to indirectly support abortion.
Indirect support happens in a variety of ways. For instance, the federal government set up the Medicaid program, pays for much of it, and then allows states to pay for abortions. The government provides support to hospitals, which perform abortions. The government gives money to family planning clinics for maternal health care, even though those clinics might also do abortions. In each case, the primary purpose of the spending is not encouraging abortion but by supporting institutions that also, with their own money, do abortions. That’s the status quo.
First, let’s apply this principle to the “public option” — a new, government-backed insurance plan that may or may not be included in a final health reform bill. Congress could decree that the basic public insurance option doesn’t include abortion but then offer consumers the ability to buy, with their own money, a rider to the policy that would cover abortions. Then the full direct cost of abortion coverage would be unambiguously carried by the consumer who chooses it.
Would there be an indirect subsidy? Yes, in the sense that the whole structure wouldn’t exist without government support, but since the purpose of the structure is providing health care in general, not promoting abortion, it seems like a valid indirect subsidy consistent with the operating principles of the status quo stalemate.
Some pro-choice folks might say, well, no one plans an unintended pregnancy so it’s not realistic for people to make that choice when buying health insurance.
But I don’t plan on having auto accidents and yet I buy car insurance; I don’t intend for my house to burn down, yet I buy homeowners insurance.
And perhaps there’s a way of having this special abortion rider also include extra benefits to pay for contraception. That would give a second reason to buy the plan, and might even prevent more unintended pregnancies and abortions.
Most health bills also include subsidies to help people buy either private or public insurance if they can’t afford it on their own. Pro-lifers have complained that government will end up subsidizing plans that cover abortion.
One solution would be to have the subsidies take the form of vouchers to individuals rather than government checks to specific plans. If individuals choose plans that cover abortions, that’s their choice. Pro-lifers wouldn’t complain if the government gave a general tax cut, which an individual then used to pay for an insurance plan that covered abortion. It’s like when the government gives a Pell grant to someone who then uses it at a Catholic College. That’s not viewed as a direct subsidy of a religious entity — which would be a violation of separation of church and state — because it is first and foremost aid to a person not an institution. Let’s apply the same principle to health care aid.
It seems to me this approach would allow many plans to cover abortion but never put pro-life citizens in the position of feeling that their tax dollars are going to pay for abortions.
Well, what do you think? Have we found neutral ground yet? What do you suggest?
UPDATE: Some positive reaction from the pro-life community to this proposal. Bill Donohue of the Catholic League said “it could break the deadlock in Catholic circles” and Richard Doerflinger of the Bishops Conference said, “such a crazy idea that it might just work.”
UPDATE 2: It occurs to me you could use the “rider” concept not only for the public option part but the subsidies-for-private-insurance section of health care reform too. You could say that prohibit plans that are in the exchange from covering abortion but then make available a supplemental rider that consumers could buy, with their own money, to pay for abortion.Adapted from an article on Wall Street Journal Online

Steve, I’d like to know the names of the “pro-choice leaders” who “don’t intend to use health care reform to shift the balance of power in their direction.” Well, “power” may be the wrong word. The right word would be “money.”
And of course this is what the abortion industry is after. No healthcare plan will pass Congress without the door remaining open for public funding of abortion or mandated coverage of abortion by private insurers.
As it stands, abortion isn’t mentioned. The various versions of the bill state either a committee will later determine what is or isn’t covered or the Health & Human Services secretary (http://is.gd/2fAb8), i.e., Kathleen Sebelius. So only the most naive person should not expect abortion to end up covered.
And if it strangely isn’t pro-aborts will sue in court, and the courts since Roe v. Wade have determined abortion is healthcare.
So I’m afraid your attempt to find common ground is futile. I repeat, either abortion remains an overt or covert option in the healthcare plan, or the healthcare plan WILL NOT PASS.
That said, Republicans have been suggesting a health insurance voucher system in the form of tax credits for some time. Remember John McCain and his $5k idea that Obama scoffed at?

Steve, I like the proposal. 23 + members of congress have signed a letter to Nancy Pelosi to stating that they will not sign a bill with that covers abortion. However, my concern is far too many private insurance co’s cover abortion, and although we would like to believe that we have choice in our coverage, we really don’t. The market is dominated by 5 large insurance companies, where 94% of the market is deemed “highly concentrated.” Most of us have no choice in the matter, as our insurance is gracefully provided by our employer, who makes that moral judgement call. It just seems a bit hypochritical to only point out the public option, without addressing the private insurers as well. But, all the same, thanks for your proposal. It sounds very fair, and I pray that something similar to this makes it in the final bill.

I like the proposal. I work for a municipality whose private coverage includes paying for abortions for a varity of reasons as well as elective abortions. City resident’s tax payer dollars pay for the coverage. State employee health coverage likely also covers abortions. State resident tax dollars also support these plans. Pro-life folks have never protested their tax dollars paying for these state and local private plans…at least not that I know of in CT. This seems inconsistent with the protest against a federal plan paid with US tax dollars.

The bill has now passed. I feel you did a tremendous job of proposing a legitimate, unbiased, logical solution. However, the nonsensical response of your first commenter reminds us that no matter how seemingly reasonable a proposal one makes, there will always be someone to stand in the way of reasonable solutions.
Good article, though!

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